“Brian” asks:
“What are your thoughts about hypnosis as a form of therapy? I’m considering seeking out a therapist who specializes in this to help me with some personal stress and issues at home.”
Dr. Einhorn replies:
Thanks for your question, Brian. I think hypnosis can be a very useful part of therapy, but I don’t use it as a form of therapy by itself. I do include it as a part of therapy for some clients, along with talk therapy, which is my main method.
I'll just say a few things about hypnosis and how I use it in my practice. Trance is a natural state which occurs spontaneously, as we can see in animals as well as people, and in children as well as adults. It’s interesting that, for something so important, there’s no universally, or even generally, agreed definition of hypnosis. For purposes of this discussion, I’ll define it as a state of trance involving the partial and temporary suspension of executive functions and a restriction of attention focus to a primary stimulus in the context of a collaborative relationship whose purpose is the healing or improving of the patient or client. Relaxation training is usually a part of hypnosis. Deep relaxation can be an end in itself, or there can be an additional focus on therapeutic work in trance, called hypnotherapy. In hypnotherapy, we can access the unconscious in some respects more directly than in conscious conversation. In fact, we go in and out of trance in ordinary psychotherapy conversation without noticing it. Hypnotherapy is a way of using trance in therapy in a very focused way.
Deep relaxation, usually involving somatic or body awareness and/or guided imagery, is a great stress reducer and health improver, physically and mentally. Practicing deep relaxation for 15 minutes every day or even every other day can have a 24/7 stress reduction benefit. Deep relaxation can help a number of medical conditions, including hypertension and irritable bowel syndrome, as well as reducing anxiety and panic. Deep relaxation supports immune function in general, probably through helping to stabilize mood and generating healing neurochemicals such as endorphins. It's not a magic cure or a one-time one; you have to practice to get good at it, and keep practicing to continue to benefit from it. While it can take shorter or longer periods for different people to learn to relax deeply, once we learne how we can usually put ourselves into a more deeply relaxed state in a few seconds or minutes, depending on how upset or distracted we are when we begin.
Hypnotherapy takes trance into the work of psychodynamic psychotherapy. “Psychodynamic” is another one of those words that means different things to different people. I’m using it here to mean therapy that acknowledges the importance of unconscious processes and works with unconscious as well as conscious mental processes, such as thoughts, feelings, impressions, perceptions, associations, etc. The trance state allows a certain degree of direct access to unconscious process, which can sometimes help identity issues and impasses (an impasse is a place where we’re stuck, we can’t pass through it) in the person’s life or therapy. Those “issues and impasses” can sometimes be partly resolved in hypnotherapy, although more often they are worked through in the talk therapy that follows. Sometimes that working through can be done in a relatively short time, sometimes it takes a longer time. I want to emphasize that because hypnosis has a reputation as a quick fix, but it is not usually one, in my experience, and that is not how I use it.
So, hypnosis can add value to therapy, but I use it as a part of overall therapy and not as a stand alone method. Incidentally, I did write a song to help people relax and go to sleep using hypnotic imagery on my new CD. The CD is "The Elephant In The Dark" (which will soon be available on www.elephantinthedark.com) and the song is "Deeper and Deeper." I recommend that people listen to it four times through, which will be about 16 minutes; and of course not when they are driving or doing anything that they have to be alert for, only when it's safe to relax deeply and even go to sleep.
Monday, September 5, 2011
Monday, July 18, 2011
Logical Nonsense
Words can lose their meaning, and when they do, utterance becomes nonsense, even it it seems logical.
This example of logical nonsense was reported by Peter S. Latham, J.D., and Patricia H. Latham, J.D., in Newsbriefs, the newsletter of the Learning Disabilities Association of America (November-December, 2009, Volume 44, No. 5).
A child with learning and attention disorders in a public school district had been described by his teachers as having trouble paying attention in class and completing his assignments. His problems got worse in high school and his mother asked the school district for a psychological evaluation. School psychologists evaluated the child and concluded that he did not qualify for special education services, in an evaluation which was subsequently found to be legally inadequate. The child’s parents sought private professional evaluation which resulted in a formal diagnosis of ADHD and several forms of learning disability. The private specialist recommended placement in a structured, residential learning environment, and his parents enrolled him in a private academy serving children with special needs.
His parents notified the school district of the private placement and sought a due process hearing to require the school district to pay for it. The hearing resulted in the determination that the school district had not offered an appropriate education and confirmed that the private school placement was appropriate, so the school district had to pay for it.
The school district sought judicial review in U.S. District Court, on the basis--here is the logical nonsense--that the child’s parents were barred from reimbursement for his private special education placement because he had not previously received special education services. Of course, the reason why he had not received special education services was because the school's psychologists had found him ineligible on the basis of an inadequate assessment.
The U. S. District Court, unable to discern between logic and nonsense, agreed with the school district’s reasoning. The parents appealed that ruling to Circuit Court which, restoring sense, reversed on the grounds that eligibility for private special education wasn’t conditional on having first received special education in the public schools. The school district appealed to the state Supreme Court, which upheld the Circuit Court's finding for the parents. So sense won out in the end, this time at least.
D. L. Pendlebury, commenting on the depth of language that he could not include in his translation of sections of the Afghan Sufi poet Hakim Sanai's "The Walled Garden of Truth" (published by Octagon, London), reflects on the way "the hypnotic power of linear verbal communication" underlies the loss of meaning in speech in Western societies. "We are effectively anesthetized to words; and perhaps precisely for that very reason we have been more enslaved by them than any other culture in history..." (p. 62)
I can't help wondering whether the school district's attorneys and administrators really believed their nonsense or whether they felt that they had to come up with something and that was the best they could do. And I can't help wondering whether the U. S. District Court judge who held for the school district really believed the school district's nonsense, or whether he (or she) knew it was nonsense but felt compelled to support the school district for some other reasons.
A lot of psychotherapy is about restoring sense to language from which sense has become separated.
This example of logical nonsense was reported by Peter S. Latham, J.D., and Patricia H. Latham, J.D., in Newsbriefs, the newsletter of the Learning Disabilities Association of America (November-December, 2009, Volume 44, No. 5).
A child with learning and attention disorders in a public school district had been described by his teachers as having trouble paying attention in class and completing his assignments. His problems got worse in high school and his mother asked the school district for a psychological evaluation. School psychologists evaluated the child and concluded that he did not qualify for special education services, in an evaluation which was subsequently found to be legally inadequate. The child’s parents sought private professional evaluation which resulted in a formal diagnosis of ADHD and several forms of learning disability. The private specialist recommended placement in a structured, residential learning environment, and his parents enrolled him in a private academy serving children with special needs.
His parents notified the school district of the private placement and sought a due process hearing to require the school district to pay for it. The hearing resulted in the determination that the school district had not offered an appropriate education and confirmed that the private school placement was appropriate, so the school district had to pay for it.
The school district sought judicial review in U.S. District Court, on the basis--here is the logical nonsense--that the child’s parents were barred from reimbursement for his private special education placement because he had not previously received special education services. Of course, the reason why he had not received special education services was because the school's psychologists had found him ineligible on the basis of an inadequate assessment.
The U. S. District Court, unable to discern between logic and nonsense, agreed with the school district’s reasoning. The parents appealed that ruling to Circuit Court which, restoring sense, reversed on the grounds that eligibility for private special education wasn’t conditional on having first received special education in the public schools. The school district appealed to the state Supreme Court, which upheld the Circuit Court's finding for the parents. So sense won out in the end, this time at least.
D. L. Pendlebury, commenting on the depth of language that he could not include in his translation of sections of the Afghan Sufi poet Hakim Sanai's "The Walled Garden of Truth" (published by Octagon, London), reflects on the way "the hypnotic power of linear verbal communication" underlies the loss of meaning in speech in Western societies. "We are effectively anesthetized to words; and perhaps precisely for that very reason we have been more enslaved by them than any other culture in history..." (p. 62)
I can't help wondering whether the school district's attorneys and administrators really believed their nonsense or whether they felt that they had to come up with something and that was the best they could do. And I can't help wondering whether the U. S. District Court judge who held for the school district really believed the school district's nonsense, or whether he (or she) knew it was nonsense but felt compelled to support the school district for some other reasons.
A lot of psychotherapy is about restoring sense to language from which sense has become separated.
Thursday, June 30, 2011
Client Comments
Among some old files I found a group of notes I’d written of comments that various clients had made, which had impressed me as particularly insightful or pithy, and which I'd written down after asking for, and receiving, permission to quote anonymously:
•“You think, because you’re brought up with a set of rules, that you have a set of values.”
•A client, describing early family history, said: “They were practicing Catholicism at the expense of Christianity.”
•“Her way of healing old wounds is to open them up and play with them.”
•“I’m so open-minded--but with gates.”
•"It's the unquiet spirit that breaks down the body."
•A client said, “You have to think through what you want to do and what goal you want to achieve.” I said, “Let’s do some of that now. What do you want to do, and what goal would you like to achieve?” She said, “That’s a loaded question.”
•Speaking with a client on the autistic spectrum, I said, “I’m trying to teach you that there’s something more to relationships than self-preoccupation and manners.” The client replied, “I don’t agree.”
•A client said, "I know that I've always felt like a dunce in my family. I just never said it out loud." I said, "Congratulations," for saying it out loud. "What difference does that make?" asked the client.
•Palpably describing what psychodynamic therapists call "dissociation," a client described coping with a mother's harangues: "I'd sit tight, put on a face, and not be there."
•A former client who returned to see me, commented: "Gee, the last time I saw you, you had a little more brown in your hair. What'd you do, eat something grey?"
•“You think, because you’re brought up with a set of rules, that you have a set of values.”
•A client, describing early family history, said: “They were practicing Catholicism at the expense of Christianity.”
•“Her way of healing old wounds is to open them up and play with them.”
•“I’m so open-minded--but with gates.”
•"It's the unquiet spirit that breaks down the body."
•A client said, “You have to think through what you want to do and what goal you want to achieve.” I said, “Let’s do some of that now. What do you want to do, and what goal would you like to achieve?” She said, “That’s a loaded question.”
•Speaking with a client on the autistic spectrum, I said, “I’m trying to teach you that there’s something more to relationships than self-preoccupation and manners.” The client replied, “I don’t agree.”
•A client said, "I know that I've always felt like a dunce in my family. I just never said it out loud." I said, "Congratulations," for saying it out loud. "What difference does that make?" asked the client.
•Palpably describing what psychodynamic therapists call "dissociation," a client described coping with a mother's harangues: "I'd sit tight, put on a face, and not be there."
•A former client who returned to see me, commented: "Gee, the last time I saw you, you had a little more brown in your hair. What'd you do, eat something grey?"
Saturday, June 11, 2011
Coaching and Psychotherapy
A colleague asked how I understand the difference between coaching and psychotherapy, and how I use Skype. Here's my reply:
Dear .......
Sorry for not being able to reply sooner to your question about services I offer to coaching clients, where I draw the line between coaching and psychotherapy, and where Skype fits in.
I offer coaching services to clients who want to improve their personal and professional effectiveness in areas where I can add value. That includes the human relations side of supervision, leadership in organizations, and the learning styles and outcomes side of education. Clients consult with me around career issues, to help them reflect on their careers and see if they might want to modify or change them, as well as for help with job searches. Clients may seek coaching for evaluating and improving their relationship skills, whether personally (with a spouse or partner) or professionally (with a supervisor and/or colleagues). Parents may wish to improve their parenting skills. In the organizational consulting side of my practice, I've learned something about helping people to develop attitudes and skills for having difficult conversations more effectively, and sometimes people come for that. Some clients come for help in understanding their learning styles and how to learn more effectively given their particular cognitive and personality styles. Relaxation training can be a part of coaching, where the client can benefit from it as a health enhancement rather than as a treatment for a diagnosable mental disorder.
Where I draw the line is between these kinds of mentoring/coaching/consulting/counseling (in the sense of providing counsel) activities and psychotherapy as a treatment for a mental illness. Therapy patients qualify for a DSM-IV diagnosis of a mental disorder, and psychotherapy is a treatment for that and has a procedure code on the bill or receipt which patients submit to third party payers.
Sometimes a coaching client is actually in psychotherapy already with another therapist, to which coaching can be complementary, but the foci are different and neither coaching nor therapy replaces the other. In coaching mode, I've said things like, "This is what I advise you to do in order to take the next step toward achieving your goal. If you have a problem doing it, you should talk to your psychotherapist about it." And, while it isn't always the case, my coaching clients often come at less than weekly intervals; semimonthly (EOW), monthly or at even longer intervals, and usually that's fine with me, but I've declined to work with potential psychotherapy patients who weren't available for the session frequency that I felt was appropriate to the presentation and intensity of their symptoms.
About Skype: My current practice is to offer psychotherapy in my office, and only to add remote methods (Skype, telephone) if the person moves out of the area (or, on occasion, is too ill to come to the office) after getting a good start to the therapeutic relationship in person. That's because there are intuitive aspects of the therapeutic relationship that require personal presence; at least as I understand and practice psychotherapy. So I don't offer psychotherapy, in the sense of a treatment for a mental disorder, remotely from the beginning. I do offer coaching, consultation and counsel from the beginning via Skype or telephone. .
I hope that helps.
Best,
Jay
Dear .......
Sorry for not being able to reply sooner to your question about services I offer to coaching clients, where I draw the line between coaching and psychotherapy, and where Skype fits in.
I offer coaching services to clients who want to improve their personal and professional effectiveness in areas where I can add value. That includes the human relations side of supervision, leadership in organizations, and the learning styles and outcomes side of education. Clients consult with me around career issues, to help them reflect on their careers and see if they might want to modify or change them, as well as for help with job searches. Clients may seek coaching for evaluating and improving their relationship skills, whether personally (with a spouse or partner) or professionally (with a supervisor and/or colleagues). Parents may wish to improve their parenting skills. In the organizational consulting side of my practice, I've learned something about helping people to develop attitudes and skills for having difficult conversations more effectively, and sometimes people come for that. Some clients come for help in understanding their learning styles and how to learn more effectively given their particular cognitive and personality styles. Relaxation training can be a part of coaching, where the client can benefit from it as a health enhancement rather than as a treatment for a diagnosable mental disorder.
Where I draw the line is between these kinds of mentoring/coaching/consulting/counseling (in the sense of providing counsel) activities and psychotherapy as a treatment for a mental illness. Therapy patients qualify for a DSM-IV diagnosis of a mental disorder, and psychotherapy is a treatment for that and has a procedure code on the bill or receipt which patients submit to third party payers.
Sometimes a coaching client is actually in psychotherapy already with another therapist, to which coaching can be complementary, but the foci are different and neither coaching nor therapy replaces the other. In coaching mode, I've said things like, "This is what I advise you to do in order to take the next step toward achieving your goal. If you have a problem doing it, you should talk to your psychotherapist about it." And, while it isn't always the case, my coaching clients often come at less than weekly intervals; semimonthly (EOW), monthly or at even longer intervals, and usually that's fine with me, but I've declined to work with potential psychotherapy patients who weren't available for the session frequency that I felt was appropriate to the presentation and intensity of their symptoms.
About Skype: My current practice is to offer psychotherapy in my office, and only to add remote methods (Skype, telephone) if the person moves out of the area (or, on occasion, is too ill to come to the office) after getting a good start to the therapeutic relationship in person. That's because there are intuitive aspects of the therapeutic relationship that require personal presence; at least as I understand and practice psychotherapy. So I don't offer psychotherapy, in the sense of a treatment for a mental disorder, remotely from the beginning. I do offer coaching, consultation and counsel from the beginning via Skype or telephone. .
I hope that helps.
Best,
Jay
Sunday, May 1, 2011
Fat, Muscle and Bone
(originally published in the spring, 2011, Illinois Psychologist, the newsletter of the Illinois Psychological Association)
In the early 1980s I was teaching organizational psychology at The Management Center of Aurora University, where my students were mostly first-level through mid-level supervisors and managers from companies and organizations along the Fox River valley. It was the era of leveraged buyouts, and one student spoke simply and eloquently about the effects of multiple takeovers on his company. “The first time we were purchased it was good for us. The new ownership got rid of fat, and we became lean and efficient. The second time we were bought, the reductions and layoffs imposed by the new owners to pay off the debt of the acquisition cut into muscle. Now we’ve been bought again, and this time they’re cutting into bone.”
A decade or so later I was in private practice, on the panel of an insurance company. A parent called me about an adolescent, an early high school student in severe crisis. The adolescent--let’s call him “Jack”--turned out to have an agitated depression with psychotic features. The insurance company’s treatment authorizer, a social worker, was supportive of intensive outpatient treatment as an alternative to hospitalization. Working collaboratively with Jack’s psychiatrist, who prescribed a combination of antipsychotic and antidepressant medications, I began seeing him three times a week in individual and family therapy. Treatment worked, Jack gradually improved, and it became possible over time to discontinue antipsychotic medication and reduce therapy frequency to twice weekly, then to once, over a period of about a year and a half.
Jack began his senior year relatively stable, on once weekly, mostly individual, therapy and 80 mg. of antidepressant medication. I submitted a treatment plan, which Jack, his parent, and his psychiatrist all supported, to continue weekly therapy throughout his senior year with the goal of eventually discontinuing antidepressant medication. By that time a psychologist had become Jack’s treatment authorizer for the insurance company, and he disallowed continuing therapy; explaining that, since Jack was stable on medication, further therapy was not indicated. The fact that weekly therapy was contributing to Jack’s stability wasn’t noted by that psychologist, who was content to leave the patient on antidepressant medications and call treatment complete. What was therapeutic muscle and bone, to me, to the patient, to his parent, and to his psychiatrist, was fat to the psychologist working for the insurance company.
I resigned from that insurance company’s panel, negotiated a fee with Jack’s parent, and successfully completed the treatment plan. At the time I was on the affiliate staff of a hospital where a psychiatrist consulted for the insurance company, and I asked him why the company’s policy had changed so much over the course of a few years. “The company’s been bought twice since you starting treating that patient,” he told me, and it had acquired a lot of debt to pay off. “It’s all about the bottom line, now.”
Most psychologists who provide therapy do so as sole practitioners, in small groups, or in small community agencies. The insurance and managed care companies that provide or manage third party payment, on the other hand, are usually very large organizations with substantial needs to manage costs in order to pay down debt associated with purchase or other expenditures, and reward owners or shareholders for their investments. So when a psychologist-practitioner speaks with a psychologist (or other mental health professional) working for an insurance or managed care company about authorizing psychotherapy, there can be quite a difference of perspective when it comes to perceptions about what is fat, what is muscle, and what is bone, when it comes to patient needs and treatment.
Because of this and similar experiences, addressing the gap between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations has been a goal of mine since becoming a Council member a couple of years ago. I am currently facilitating an ad hoc committee of Council members drafting an aspirational statement regarding the relationship between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care companies, for presentation to the Council. Surely the foundations of such a relationship include mutual acknowledgement that the patient’s best interests is a core value shared by both providers and payers, and also acknowledgement that we are all stakeholders, as taxpayers and insurance rate-payers, in a system in which we all want to provide necessary services to people who need them in an economically viable way. Let’s see if there’s a middle ground where psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations can meet collegially, when we discuss the fat, muscle and bone of psychotherapy.
In the early 1980s I was teaching organizational psychology at The Management Center of Aurora University, where my students were mostly first-level through mid-level supervisors and managers from companies and organizations along the Fox River valley. It was the era of leveraged buyouts, and one student spoke simply and eloquently about the effects of multiple takeovers on his company. “The first time we were purchased it was good for us. The new ownership got rid of fat, and we became lean and efficient. The second time we were bought, the reductions and layoffs imposed by the new owners to pay off the debt of the acquisition cut into muscle. Now we’ve been bought again, and this time they’re cutting into bone.”
A decade or so later I was in private practice, on the panel of an insurance company. A parent called me about an adolescent, an early high school student in severe crisis. The adolescent--let’s call him “Jack”--turned out to have an agitated depression with psychotic features. The insurance company’s treatment authorizer, a social worker, was supportive of intensive outpatient treatment as an alternative to hospitalization. Working collaboratively with Jack’s psychiatrist, who prescribed a combination of antipsychotic and antidepressant medications, I began seeing him three times a week in individual and family therapy. Treatment worked, Jack gradually improved, and it became possible over time to discontinue antipsychotic medication and reduce therapy frequency to twice weekly, then to once, over a period of about a year and a half.
Jack began his senior year relatively stable, on once weekly, mostly individual, therapy and 80 mg. of antidepressant medication. I submitted a treatment plan, which Jack, his parent, and his psychiatrist all supported, to continue weekly therapy throughout his senior year with the goal of eventually discontinuing antidepressant medication. By that time a psychologist had become Jack’s treatment authorizer for the insurance company, and he disallowed continuing therapy; explaining that, since Jack was stable on medication, further therapy was not indicated. The fact that weekly therapy was contributing to Jack’s stability wasn’t noted by that psychologist, who was content to leave the patient on antidepressant medications and call treatment complete. What was therapeutic muscle and bone, to me, to the patient, to his parent, and to his psychiatrist, was fat to the psychologist working for the insurance company.
I resigned from that insurance company’s panel, negotiated a fee with Jack’s parent, and successfully completed the treatment plan. At the time I was on the affiliate staff of a hospital where a psychiatrist consulted for the insurance company, and I asked him why the company’s policy had changed so much over the course of a few years. “The company’s been bought twice since you starting treating that patient,” he told me, and it had acquired a lot of debt to pay off. “It’s all about the bottom line, now.”
Most psychologists who provide therapy do so as sole practitioners, in small groups, or in small community agencies. The insurance and managed care companies that provide or manage third party payment, on the other hand, are usually very large organizations with substantial needs to manage costs in order to pay down debt associated with purchase or other expenditures, and reward owners or shareholders for their investments. So when a psychologist-practitioner speaks with a psychologist (or other mental health professional) working for an insurance or managed care company about authorizing psychotherapy, there can be quite a difference of perspective when it comes to perceptions about what is fat, what is muscle, and what is bone, when it comes to patient needs and treatment.
Because of this and similar experiences, addressing the gap between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations has been a goal of mine since becoming a Council member a couple of years ago. I am currently facilitating an ad hoc committee of Council members drafting an aspirational statement regarding the relationship between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care companies, for presentation to the Council. Surely the foundations of such a relationship include mutual acknowledgement that the patient’s best interests is a core value shared by both providers and payers, and also acknowledgement that we are all stakeholders, as taxpayers and insurance rate-payers, in a system in which we all want to provide necessary services to people who need them in an economically viable way. Let’s see if there’s a middle ground where psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations can meet collegially, when we discuss the fat, muscle and bone of psychotherapy.
Sunday, April 10, 2011
Marital Therapy and Infidelity
On April 9, 2011, I gave a presentation on marital therapy of infidelity, as part of a series of presentations on couples therapy sponsored by the Illinois Psychological Association. A presentation by Carol Cradock, Ph.D., on counseling couples who are in the process of divorcing, preceded mine. Northwestern University Medill School of Journalism student Helen Adamopoulos was there and wrote an article on our presentations. I've copied the text here. You can access the article itself, with a great picture of Carol in action, at:
http://news.medill.northwestern.edu/chicago/news.aspx?id=184617
Here's the text:
Therapists learn how to counsel couples on divorce, cheating
BY HELEN ADAMOPOULOS
APRIL 08, 2011
Dr. Jay Einhorn scanned the small classroom, where about 30 psychologists and therapists sat watching him.
“It would be fun to ask for a show of hands,” he said with a grin. “How many people have been unfaithful?”
The room erupted with laughter as people glanced around at each other. No one raised his or her hand.
Although no one in that classroom was willing to admit it, Einhorn said most people have probably been affected by infidelity in some way, whether they have been unfaithful themselves, been cheated on or known about someone else’s affair.
He spoke Friday morning about approaching infidelity from a therapist’s perspective as part of a workshop series on couples counseling hosted by the Illinois Psychological Association. The workshop was the fourth in a series of six sessions the association is holding on the second Friday of each month through June at the Chicago School of Professional Psychology.
Einhorn, a consulting psychologist at Roycemore School in Evanston and an independent practitioner, said there aren’t reliable statistics on the instance of infidelity, but it is evidently a common problem.
“We can estimate that many if not most divorces have to do with infidelity,” he said.
Einhorn said therapists should consider the couple’s developmental history (did they grow up in a family where infidelity was common?) as well as evaluating the relationship according to a concept called the “identity union.” The identity union refers to how the couple view themselves as one entity, rather than two separate people. They view their union as something unique and special.
“That’s what the infidelity hurts most,” Einhorn said.
Whether the couple can stay together depends on reconstructing the identity union. This cannot take place if there is ongoing infidelity, physical violence or ongoing verbal and emotional attacks, he said. The betrayed or “hurt” partner needs to realize that the couple’s former identity union was partly an illusion; the relationship wasn’t what the betrayed spouse thought it was. If the hurt partner can come to terms with that, there is a better chance of healing the marriage, Einhorn said.
In turn, the unfaithful partner should examine how the identity union wasn’t meeting his or her needs. Integrating those needs into the framework of the marriage is a key part of couples therapy, he said.
If a couple decides they can’t or don’t want to salvage their relationship, therapists can employ strategies to try to minimize the personal damage for both people. Chicago psychologist Dr. Carroll Cradock, who has worked extensively with couples in the process of separating, also spoke at the workshop about improving divorce outcomes.
“Divorce is a life transition, one of life’s most difficult transitions,” Cradock said.
She compared the process to “trying to steer a boat across Lake Michigan during a storm.” However, therapists can guide couples and their children through those dangerous waters.
Cradock staged a mock therapy session to demonstrate how to deal with a separating couple. First, she showed a clip from “The Squid and the Whale,” a movie centering on a family dealing with divorce. Then two workshop participants pretended to be the parents from the film, while Cradock counseled them.
She asked them what they wanted for their family, such as both parents maintaining strong attachments with their children. Cradock said that she would also speak to the children alone to find out what they wanted, and then combine that with the parents’ wishes to form a family mission statement.
“It’s a road map for them,” she said.
Rita Guertin, a therapist at Alexian Brothers Behavioral Health Hospital in Hoffman Estates, said she found the workshop useful and engaging.
“I liked doing this little vignette here,” she said of Cradock’s role-playing exercise. “I’m a really visual person.”
Guertin said she was attending the entire workshop series because she wants to open her own practice one day and needs to learn about working with couples first. Clinicians can earn a maximum of 39 continuing education credits (6.5 each day) by participating in the series.
For more information on the workshop series, visit www.illinoispsychology.org.
http://news.medill.northwestern.edu/chicago/news.aspx?id=184617
Here's the text:
Therapists learn how to counsel couples on divorce, cheating
BY HELEN ADAMOPOULOS
APRIL 08, 2011
Dr. Jay Einhorn scanned the small classroom, where about 30 psychologists and therapists sat watching him.
“It would be fun to ask for a show of hands,” he said with a grin. “How many people have been unfaithful?”
The room erupted with laughter as people glanced around at each other. No one raised his or her hand.
Although no one in that classroom was willing to admit it, Einhorn said most people have probably been affected by infidelity in some way, whether they have been unfaithful themselves, been cheated on or known about someone else’s affair.
He spoke Friday morning about approaching infidelity from a therapist’s perspective as part of a workshop series on couples counseling hosted by the Illinois Psychological Association. The workshop was the fourth in a series of six sessions the association is holding on the second Friday of each month through June at the Chicago School of Professional Psychology.
Einhorn, a consulting psychologist at Roycemore School in Evanston and an independent practitioner, said there aren’t reliable statistics on the instance of infidelity, but it is evidently a common problem.
“We can estimate that many if not most divorces have to do with infidelity,” he said.
Einhorn said therapists should consider the couple’s developmental history (did they grow up in a family where infidelity was common?) as well as evaluating the relationship according to a concept called the “identity union.” The identity union refers to how the couple view themselves as one entity, rather than two separate people. They view their union as something unique and special.
“That’s what the infidelity hurts most,” Einhorn said.
Whether the couple can stay together depends on reconstructing the identity union. This cannot take place if there is ongoing infidelity, physical violence or ongoing verbal and emotional attacks, he said. The betrayed or “hurt” partner needs to realize that the couple’s former identity union was partly an illusion; the relationship wasn’t what the betrayed spouse thought it was. If the hurt partner can come to terms with that, there is a better chance of healing the marriage, Einhorn said.
In turn, the unfaithful partner should examine how the identity union wasn’t meeting his or her needs. Integrating those needs into the framework of the marriage is a key part of couples therapy, he said.
If a couple decides they can’t or don’t want to salvage their relationship, therapists can employ strategies to try to minimize the personal damage for both people. Chicago psychologist Dr. Carroll Cradock, who has worked extensively with couples in the process of separating, also spoke at the workshop about improving divorce outcomes.
“Divorce is a life transition, one of life’s most difficult transitions,” Cradock said.
She compared the process to “trying to steer a boat across Lake Michigan during a storm.” However, therapists can guide couples and their children through those dangerous waters.
Cradock staged a mock therapy session to demonstrate how to deal with a separating couple. First, she showed a clip from “The Squid and the Whale,” a movie centering on a family dealing with divorce. Then two workshop participants pretended to be the parents from the film, while Cradock counseled them.
She asked them what they wanted for their family, such as both parents maintaining strong attachments with their children. Cradock said that she would also speak to the children alone to find out what they wanted, and then combine that with the parents’ wishes to form a family mission statement.
“It’s a road map for them,” she said.
Rita Guertin, a therapist at Alexian Brothers Behavioral Health Hospital in Hoffman Estates, said she found the workshop useful and engaging.
“I liked doing this little vignette here,” she said of Cradock’s role-playing exercise. “I’m a really visual person.”
Guertin said she was attending the entire workshop series because she wants to open her own practice one day and needs to learn about working with couples first. Clinicians can earn a maximum of 39 continuing education credits (6.5 each day) by participating in the series.
For more information on the workshop series, visit www.illinoispsychology.org.
Saturday, April 2, 2011
Diagnosing Attention Deficit Disorder
Several colleagues on a listserve asked questions or made comments about diagnosing attention deficit disorder, which moved me to write this reply.
When we look at diagnosing attention deficit disorder, it’s important to remember that there are three moving targets.
The first moving target is our knowledge of attention and how attention works in the brain, which is not simple. The frontal lobes are largely involved in deciding what to focus on, maintaining focus, inhibiting distractions, monitoring appropriateness of focus, evaluating effectiveness of focus, and transitioning to a new focus when that is appropriate, within a huge constant stream of perceptual and sub-perceptual inputs from both the world around us and from within our own bodies. (See Elkhonon Goldberg, “The New Executive Brain.”) Our knowledge of what the frontal lobes do and how to evaluate frontal lobe dysfunction is relatively recent and constantly growing.
The second moving target is the definition and description of attention disorders. Society itself is changing, including norms and expectations about how children and adults should behave. Styles of attention that would have been normal throughout most of human history, when children would have been running around the woods, helping around the house or in the fields, or apprenticing in some craft or business, become disorders when children and adults spend most of their time in schools or offices, seated rather than moving and focusing on abstract tasks. And professional culture is continuously modifying its concepts about what qualifies as attention disorder; DSM V is in preparation, for example.
The third moving target is the experience of the diagnostician. If we say, for example, that physicians and psychologists typically diagnose attention disorders, that places the focus on how physicians as such and psychologists as such make diagnoses. However, a closer look at how actual physicians and actual psychologists go about diagnosing attention deficit disorders shows large discrepancies not only between groups but also within them. Much of the training, in fact, is obtained on the job, and experience matters.
It is usually psychologists or physicians who make the diagnosis. Physicians usually make the diagnosis based on a clinical interview, and psychologists usually make the diagnosis based on interview(s) and testing. Both physicians and psychologists may ask third parties (often parents, teachers, spouses, sometimes supervisors, siblings or significant others) for input, either in interviews or by completing rating forms. Among physicians, pediatricians, psychiatrists, and neurologists are the usual diagnosticians, although any physician can legally make the diagnosis. Among psychologists, clinical psychologists and neuropsychologists are the usual diagnosticians, although school psychologists are increasingly making the diagnosis, especially those in private practice.
Because attention is so complex, there are a number of different ways in which it can be disordered, all of which require some compensatory strategies to manage behaviorally, and not all of which respond equally well to medication. What might be called the “classical” hyperactive type of attention disorder, the impulsive, distractible, hyperenergetic presentation, often shows the paradoxical response of slowing down when stimulants are administered. This paradoxical response has been explained by psychologist Russell Barkley’s theory of inhibitory undersupply. The structures in what’s usually called the limbic system send arousing signals to the upper parts of the frontal lobes, which select which signals to attend to and which ones to inhibit, which they accomplish through inhibitory tracts signaling downward. Barclay’s theory is that the inhibitory tracts from the frontal lobes to the limbic system structures are undersupplied with modulating and/or transmitting neurochemicals (probably especially dopamine) in hyperactive people, so they don’t work very well. When stimulant is administered to hyperactive people, his theory goes, it is selectively channeled to the neurochemically undersupplied inhibitory tracts, which creates the paradoxical effect of a hyperactive person being slowed down by taking a stimulant. For that reason, I call stimulants for classically hyperactive people, “brake fluid.” (Elkhonon Goldberg includes limbic structures as part of the lower frontal lobes, in which case we’d be talking about intra-lobe communications, which doesn’t really alter Barclay’s model, just how we talk about it.)
The diagnosis for people within what might be called this original paradigm of hyperactive attention disorder was relatively straightforward. Observation of the child in school, or a good case history supported by observations of parents and teachers, was sufficient to establish the pattern. Some hyperactive kids are obviously hyper in the doctor’s office, others can keep it together for one or several interviews, but the case history, supported by corroborating observations from school and home (or work, in an adult), was sufficient. So an experienced physician or psychologist, doing an office interview, usually with supporting evidence from parents, teachers, etc., can make this diagnosis quite well for the “standard model” of hyperactive patient, as long as there aren’t any significant rule-outs. (The diagnostician may have received the referral from a therapist who already suspects hyperactivity and can supply more background information to support the diagnosis.) But that’s where things can get complicated.
The more we learn about frontal lobe functioning and attention, and the more clinical observations we accumulate as the diagnosis becomes more common, the more obvious it becomes that this original hyperactive syndrome is only one of a wide range of possible issues with attention with which patients present. For example, people with nonverbal learning disorders, in which the relational functions usually associated with the right cerebral hemisphere, and especially the right frontal lobe, are deficient (often accompanied by a substantial discrepancy between higher verbal scores a lower nonverbal scores across a number of tests), often appear disorganized, unable to select and maintain appropriate task focus, distractible, etc., and so they present a behavioral picture very much like that of many hyperactive people; but they are not classically hyperactive, and they do not respond to stimulants by slowing down. People with sequential processing deficiencies (who may or may not have the opposite test score pattern, with higher nonverbal than verbal scores) may have difficulty perceiving information that comes in a series or sequence (as most language does), and have difficulty organizing and following through a multi-step process. Stimulants affect people with such cognitive styles as these like they affect most people; that is, by general arousal. Sometimes that helps--for the same reasons that stimulants can help high school and college students without attention disorders to cram for final exams--but they can also just stimulate the entire system, thus increasing distractibility and disorganization. And issues of stimulant dependence may be of more concern with this population than with the hyperactive folks for whom stimulants act like brake fluid. Although it used to be boys who were mainly found to be hyperactive, as professional awareness of non-hyperactive inattention as a form of attention deficit increases, more girls and women are found to have forms of attention disorder that are not of the classically hyperactive kind and do not respond to stimulants in the paradoxical, efficacious way.
And the picture gets even more complicated by other cognitive information processing styles that can be mistaken for primary attention disorders. For example, some people have a deficiency in processing language which they hear, an auditory language processing disorder, even though their sensory hearing is normal and they are fluent in speaking. This can be due to central auditory processing disorder, which has to be diagnosed by an audiologist who knows how to do it; but there are speech and language tests that can indicate its presence, if the evaluator has learned about it. Some people who seem to have an attention disorder because they don’t retain what they read actually retain better when they read aloud, or use a reading method such as SQ3R to support memory and comprehension. Their disorder is with language processing, a kind of dyslexia, rather than with attention per se; though the child may look inattentive in class or the adult in the office. Some people have limited processing speed--they may have lots of intelligence, but need to learn at a slower pace than most of their peers, although they can learn a great deal if they have the time. Some people have limited processing capacity, their cognitive “house” is like an igloo that can only admit a small amount of information at a time, even though the interior may be quite large. Some people have deficiencies at making new learning automatic (which probably involves circuits extending from the frontal lobes into the cerebellum). Any of these people, in a clinical interview, can look as if they have a primary attention disorder.
It’s not only learning and language disorders that can sometimes look like attention disorders; so can emotional and personality disorders. If someone is anxious, depressed, subject to powerful mood swings, or has a self-defeating personality tendency or disorder of one sort or another, that can show up as underachievement, difficulty focusing, disorganization, etc.; in other words, it can look, on superficial review, like a primary attention disorder. I once evaluated a physician, a very bright person indeed, for ADD/ADHD, and found that he had a writing disorder (a specific learning disability) and a complex personality structure (emerging out of his personal history) that led to undermining himself at key points in his life, but not an attention disorder.
Complicating matters still further, learning and/or language and/or emotional and/or personality disorders can present together in the same person. Patients with attention deficit disorders often present with comorbidities, which just means other clinically significant conditions. I’ve seen estimates ranging from 20% to 50% of persons with attention disorders having significant comorbidities.
That brings us to testing. While there is no test for attention disorder per se (despite the fact that some tests are labeled as tests of attention), testing can paint a picture of a person’s cognitive style, can rule in or out learning disabilities such as verbal or nonverbal disorders that can be mistaken for attention disorders, and can also look more closely at emotional and personality functioning than can be done in a routine clinical interview. The comprehensiveness and extent of testing and interviewing varies a lot among practitioners. I typically conduct a long and structured initial interview, followed up with subsequent interviews of the patient during testing, and supporting interviews with parents and teachers (or spouses, with adult patients), as well as administering neuropsychological, psychoeducational (usually reading, writing, and arithmetic, to which I add expressive and receptive spoken language, which strictly speaking are in the speech and language testing domain), and personality/emotional testing, over the course of which I get to watch how the person applies himself or herself to interviewing and responding to a variety of testing challenges. This is a fairly comprehensive approach, but it obviously involves considerably more time and expense than a single clinical interview. A full evaluation typically involves 10-20 hours of testing and interviewing, after which there’s the work of integrating the test results and preparing a report that puts the test results together with the case history, and behavioral and supporting observations, gives a diagnostic impression and recommendations. A typical report of evaluation runs to 15-20 pages, only a couple of which are boilerplate; most consist of narrative and test scores.
So the issue of diagnosing attention disorders is far from a simple one. Diagnosticians need to learn about different kinds of attention disorders and other learning and emotional conditions that can look like attention disorders. For the patient, as is usually the case with any complex condition, each person and each family has to find his, her or their own way within the educational and health care systems, and will hopefully find the doctor or team which will be able to help them understand their cognitive and personal styles, for better and worse, and find their way to achieve their goals.
When we look at diagnosing attention deficit disorder, it’s important to remember that there are three moving targets.
The first moving target is our knowledge of attention and how attention works in the brain, which is not simple. The frontal lobes are largely involved in deciding what to focus on, maintaining focus, inhibiting distractions, monitoring appropriateness of focus, evaluating effectiveness of focus, and transitioning to a new focus when that is appropriate, within a huge constant stream of perceptual and sub-perceptual inputs from both the world around us and from within our own bodies. (See Elkhonon Goldberg, “The New Executive Brain.”) Our knowledge of what the frontal lobes do and how to evaluate frontal lobe dysfunction is relatively recent and constantly growing.
The second moving target is the definition and description of attention disorders. Society itself is changing, including norms and expectations about how children and adults should behave. Styles of attention that would have been normal throughout most of human history, when children would have been running around the woods, helping around the house or in the fields, or apprenticing in some craft or business, become disorders when children and adults spend most of their time in schools or offices, seated rather than moving and focusing on abstract tasks. And professional culture is continuously modifying its concepts about what qualifies as attention disorder; DSM V is in preparation, for example.
The third moving target is the experience of the diagnostician. If we say, for example, that physicians and psychologists typically diagnose attention disorders, that places the focus on how physicians as such and psychologists as such make diagnoses. However, a closer look at how actual physicians and actual psychologists go about diagnosing attention deficit disorders shows large discrepancies not only between groups but also within them. Much of the training, in fact, is obtained on the job, and experience matters.
It is usually psychologists or physicians who make the diagnosis. Physicians usually make the diagnosis based on a clinical interview, and psychologists usually make the diagnosis based on interview(s) and testing. Both physicians and psychologists may ask third parties (often parents, teachers, spouses, sometimes supervisors, siblings or significant others) for input, either in interviews or by completing rating forms. Among physicians, pediatricians, psychiatrists, and neurologists are the usual diagnosticians, although any physician can legally make the diagnosis. Among psychologists, clinical psychologists and neuropsychologists are the usual diagnosticians, although school psychologists are increasingly making the diagnosis, especially those in private practice.
Because attention is so complex, there are a number of different ways in which it can be disordered, all of which require some compensatory strategies to manage behaviorally, and not all of which respond equally well to medication. What might be called the “classical” hyperactive type of attention disorder, the impulsive, distractible, hyperenergetic presentation, often shows the paradoxical response of slowing down when stimulants are administered. This paradoxical response has been explained by psychologist Russell Barkley’s theory of inhibitory undersupply. The structures in what’s usually called the limbic system send arousing signals to the upper parts of the frontal lobes, which select which signals to attend to and which ones to inhibit, which they accomplish through inhibitory tracts signaling downward. Barclay’s theory is that the inhibitory tracts from the frontal lobes to the limbic system structures are undersupplied with modulating and/or transmitting neurochemicals (probably especially dopamine) in hyperactive people, so they don’t work very well. When stimulant is administered to hyperactive people, his theory goes, it is selectively channeled to the neurochemically undersupplied inhibitory tracts, which creates the paradoxical effect of a hyperactive person being slowed down by taking a stimulant. For that reason, I call stimulants for classically hyperactive people, “brake fluid.” (Elkhonon Goldberg includes limbic structures as part of the lower frontal lobes, in which case we’d be talking about intra-lobe communications, which doesn’t really alter Barclay’s model, just how we talk about it.)
The diagnosis for people within what might be called this original paradigm of hyperactive attention disorder was relatively straightforward. Observation of the child in school, or a good case history supported by observations of parents and teachers, was sufficient to establish the pattern. Some hyperactive kids are obviously hyper in the doctor’s office, others can keep it together for one or several interviews, but the case history, supported by corroborating observations from school and home (or work, in an adult), was sufficient. So an experienced physician or psychologist, doing an office interview, usually with supporting evidence from parents, teachers, etc., can make this diagnosis quite well for the “standard model” of hyperactive patient, as long as there aren’t any significant rule-outs. (The diagnostician may have received the referral from a therapist who already suspects hyperactivity and can supply more background information to support the diagnosis.) But that’s where things can get complicated.
The more we learn about frontal lobe functioning and attention, and the more clinical observations we accumulate as the diagnosis becomes more common, the more obvious it becomes that this original hyperactive syndrome is only one of a wide range of possible issues with attention with which patients present. For example, people with nonverbal learning disorders, in which the relational functions usually associated with the right cerebral hemisphere, and especially the right frontal lobe, are deficient (often accompanied by a substantial discrepancy between higher verbal scores a lower nonverbal scores across a number of tests), often appear disorganized, unable to select and maintain appropriate task focus, distractible, etc., and so they present a behavioral picture very much like that of many hyperactive people; but they are not classically hyperactive, and they do not respond to stimulants by slowing down. People with sequential processing deficiencies (who may or may not have the opposite test score pattern, with higher nonverbal than verbal scores) may have difficulty perceiving information that comes in a series or sequence (as most language does), and have difficulty organizing and following through a multi-step process. Stimulants affect people with such cognitive styles as these like they affect most people; that is, by general arousal. Sometimes that helps--for the same reasons that stimulants can help high school and college students without attention disorders to cram for final exams--but they can also just stimulate the entire system, thus increasing distractibility and disorganization. And issues of stimulant dependence may be of more concern with this population than with the hyperactive folks for whom stimulants act like brake fluid. Although it used to be boys who were mainly found to be hyperactive, as professional awareness of non-hyperactive inattention as a form of attention deficit increases, more girls and women are found to have forms of attention disorder that are not of the classically hyperactive kind and do not respond to stimulants in the paradoxical, efficacious way.
And the picture gets even more complicated by other cognitive information processing styles that can be mistaken for primary attention disorders. For example, some people have a deficiency in processing language which they hear, an auditory language processing disorder, even though their sensory hearing is normal and they are fluent in speaking. This can be due to central auditory processing disorder, which has to be diagnosed by an audiologist who knows how to do it; but there are speech and language tests that can indicate its presence, if the evaluator has learned about it. Some people who seem to have an attention disorder because they don’t retain what they read actually retain better when they read aloud, or use a reading method such as SQ3R to support memory and comprehension. Their disorder is with language processing, a kind of dyslexia, rather than with attention per se; though the child may look inattentive in class or the adult in the office. Some people have limited processing speed--they may have lots of intelligence, but need to learn at a slower pace than most of their peers, although they can learn a great deal if they have the time. Some people have limited processing capacity, their cognitive “house” is like an igloo that can only admit a small amount of information at a time, even though the interior may be quite large. Some people have deficiencies at making new learning automatic (which probably involves circuits extending from the frontal lobes into the cerebellum). Any of these people, in a clinical interview, can look as if they have a primary attention disorder.
It’s not only learning and language disorders that can sometimes look like attention disorders; so can emotional and personality disorders. If someone is anxious, depressed, subject to powerful mood swings, or has a self-defeating personality tendency or disorder of one sort or another, that can show up as underachievement, difficulty focusing, disorganization, etc.; in other words, it can look, on superficial review, like a primary attention disorder. I once evaluated a physician, a very bright person indeed, for ADD/ADHD, and found that he had a writing disorder (a specific learning disability) and a complex personality structure (emerging out of his personal history) that led to undermining himself at key points in his life, but not an attention disorder.
Complicating matters still further, learning and/or language and/or emotional and/or personality disorders can present together in the same person. Patients with attention deficit disorders often present with comorbidities, which just means other clinically significant conditions. I’ve seen estimates ranging from 20% to 50% of persons with attention disorders having significant comorbidities.
That brings us to testing. While there is no test for attention disorder per se (despite the fact that some tests are labeled as tests of attention), testing can paint a picture of a person’s cognitive style, can rule in or out learning disabilities such as verbal or nonverbal disorders that can be mistaken for attention disorders, and can also look more closely at emotional and personality functioning than can be done in a routine clinical interview. The comprehensiveness and extent of testing and interviewing varies a lot among practitioners. I typically conduct a long and structured initial interview, followed up with subsequent interviews of the patient during testing, and supporting interviews with parents and teachers (or spouses, with adult patients), as well as administering neuropsychological, psychoeducational (usually reading, writing, and arithmetic, to which I add expressive and receptive spoken language, which strictly speaking are in the speech and language testing domain), and personality/emotional testing, over the course of which I get to watch how the person applies himself or herself to interviewing and responding to a variety of testing challenges. This is a fairly comprehensive approach, but it obviously involves considerably more time and expense than a single clinical interview. A full evaluation typically involves 10-20 hours of testing and interviewing, after which there’s the work of integrating the test results and preparing a report that puts the test results together with the case history, and behavioral and supporting observations, gives a diagnostic impression and recommendations. A typical report of evaluation runs to 15-20 pages, only a couple of which are boilerplate; most consist of narrative and test scores.
So the issue of diagnosing attention disorders is far from a simple one. Diagnosticians need to learn about different kinds of attention disorders and other learning and emotional conditions that can look like attention disorders. For the patient, as is usually the case with any complex condition, each person and each family has to find his, her or their own way within the educational and health care systems, and will hopefully find the doctor or team which will be able to help them understand their cognitive and personal styles, for better and worse, and find their way to achieve their goals.
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